Covered and non-covered drugs - Aetna
Covered and non-covered
drugs
Drugs not covered -- and their covered alternatives for the Value and Value Plus
pharmacy plans 2019 Formulary Exclusions Drug List
05.03.924.1H (06/19)
July 2019 Formulary Exclusions Drug List
Value and Value Plus pharmacy plans
Category
Not covered
Covered alternatives
Analgesics
Panlor* (acetaminophen/caffeine/dihydrocodeine tab acetaminophen/caffeine/dihydrocodeine cap
325-30-16 mg)
320.5-30-16mg (generic TREZIX)
acetaminophen/caffeine/dihydrocodeine tab
325-30-16 mg
ALLZITAL (butalbital/acetaminophen) bupap butalbital/acetaminophen 50-300mg
butalbital/acetaminophen 50-325mg
CAMBIA (diclofenac)
CONZIP* (tramadol ER capsules)
DEXPAK 6 DAY** (dexamethasone) DEXPAK 10 DAY** (dexamethasone) DEXPAK 13** (dexamethasone) TAPERDEX 6 DAY (dexamethasone)
DUEXIS (ibuprofen/famotidine)
ANAPROX DS** (naproxen) FENORTHO* (fenoprofen calcium) FLECTOR PATCH (diclofenac epolamine) INDOCIN SUPP* (indomethacin) INDOCIN SUSP* (indomethacin) MOBIC** (meloxicam) NAPRELAN* (naproxen sodium) PENNSAID* (diclofenac sodium topical solution) SPRIX (ketorolac trometh nasal spray) TIVORBEX (indomethacin) VIVLODEX (meloxicam) VOLTAREN** (diclofenac) ZIPSOR (diclofenac potassium) ZORVOLEX (diclofenac)
diclofenac potassium (generic CATAFLAM), sumatriptan (generic IMITREX), naratriptan (generic AMERGE), rizatriptan (generic MAXALT) tramadol immediate-release or extendedrelease tablets (generic ULTRAM, ULTRAM ER) dexamethasone tab therapy pack
ibuprofen (generic MOTRIN) plus famotidine (generic PEPCID) Generic oral nonsteroidal antiinflammatory drug
*Generic product is available and is also excluded from coverage. **Generic product is available and is covered as an alternative to the brand-name product
Key UPPERCASE Lowercase italics
Brand-name medicine Generic medicine
Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna HealthAssurance Pennsylvania Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida by Aetna Health Inc. and/or Aetna Life Insurance Company. In Utah and Wyoming by Aetna Health of Utah Inc. and Aetna Life Insurance Company. In Maryland by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC.
Category
Analgesics (continued)
Not covered LAZANDA (fentanyl citrate nasal spray) SUBSYS (fentanyl sublingual spray) LIDODERM** (lidocaine) PRIMLEV (oxycodone/acetaminophen)
RYBIX ODT (tramadol)
VANATOL LQ (acetaminophen/butalbital/ caffeine)
VIMOVO (naproxen/esomeprazole)
Antibiotics
Antidotes Antihyperlipidemic Anti-infectives
ACTICLATE* (doxycycline) ADOXA* (doxycycline) AVIDOXY* (doxycycline) DORYX* (doxycycline) doxycycline hyclate 75 mg, 100 mg delayed-
release tablets doxycycline monohydrate 75 mg capsules MONODOX 75 mg* (doxycycline) MONDOXYNE NL 75 mg capsules ORACEA* (doxycycline) TARGADOX (doxycycline)
COREMINO (minocycline) DYNACIN* tablets (minocycline) MINOLIRA ER (minocycline) SOLODYN (minocycline) XIMINO (minocycline)
FURADANTIN** (nitrofurantoin oral suspension)
ZYVOX** (linezolid)
EVZIO (naloxone HCl injection)
CRESTOR** (rosuvastatin calcium)
FENOGLIDE* (fenofibrate)
LIPITOR** (atorvastatin)
FLOLIPID (simvastatin susp)
ANCOBON** (flucytosine)
NOXAFIL
SOLOSEC (secnidazole)
Covered alternatives fentanyl citrate lozenge (generic ACTIQ)
lidocaine patch 5% oxycodone/acetaminophen (generic PERCOCET, ENDOCET) tramadol immediate-release or extendedrelease tablets (generic ULTRAM, ULTRAM ER) acetaminophen/butalbital/caffeine tablet (generic FIORICET) esomeprazole magnesium (generic NEXIUM) plus naproxen (generic NAPROSYN) doxycycline monohydrate 50 mg, 100 mg capsules (generic MONODOX) doxycycline hyclate 100 mg capsules (generic VIBRAMYCIN) DOXY-D 100 mg capsules MORGIDOX 50 mg, 100 mg capsules
minocycline capsules (generic MINOCIN)
nitrofurantoin linezolid NARCAN nasal spray rosuvastatin Other generic fenofibrates atorvastatin simvastatin (generic ZOCOR) flucytosine itraconazole (generic SPORANOX) metronidazole
*Generic product is available and is also excluded from coverage. **Generic product is available and is covered as an alternative to the brand-name product
Category Antivirals
Cardiovascular
Not covered ZOVIRAX** (acyclovir)
SITAVIG (acyclovir)
TAMIFLU** (oseltamivir) AUVI-Q (epinephrine) CARDIZEM CD** (diltiazem) CADUET* (amlodipine/atorvastatin)
CAROSPIR (spironolactone susp) DIAMOX SEQUEL* (acetazolomide ER) DUTOPROL (metoprolol succinate/
hydrochlorothiazide extended-release tablets)
INDERAL LA** (propranolol ER) metoprolol succinate/hydrochlorothiazide
extended-release tablets RANEXA** (ranolazine er) TEKTURNA** (aliskiren) TEKTURNA HCT** (aliskiren-hctz) VASOTEC** (enalapril maleate) ZYPITAMAG (pitavastatin)
Central nervous system (CNS) -- antidepressants
APLENZIN (bupropion HBr) FORFIVO XL (bupropion HCl extended release) WELLBUTRIN XL** (bupropion extended
release)
LEXAPRO (escitalopram)**
PEXEVA (paroxetine)
CNS -- antiseizure
PRISTIQ** (desvenlafaxine) STAVZOR (valproic acid)
Covered alternatives
acyclovir capsules, tablets, ointment (generic ZOVIRAX) acyclovir capsules, tablets, ointment (generic ZOVIRAX) oseltamivir epinephrine injection, Epi-Pen diltiazem ER
amlodipine (generic NORVASC) plus atorvastatin (generic LIPITOR) spironolactone (generic ALDACTONE) acetazolomide (generic DIAMOX) metoprolol ER (generic TOPROL XL) plus hydrocholorothiazide, metoprolol/ hydrochlorothiazide IR (generic LOPRESS HCR) propranolol ER metoprolol/hydrochlorothiazide tablets (generic LOPRESSOR HCT)
ranolazine er (generic RANEXA) aliskiren (generic TEKTURNA) Aliskiren-hctz (generic TEKTURNA) enalapril maleate rosuvastatin, atorvastatin, simvastatin (generic CRESTOR, LIPITOR, ZOCOR) bupropion immediate or extended release (generic WELLBUTRIN, WELLBUTRIN SR, WELLBUTRIN XL)
escitalopram
paroxetine immediate or extended release (generic PAXIL, PAXIL CR) desvenlafaxine succinate tab er 24 hr valproic acid (generic DEPAKENE)
*Generic product is available and is also excluded from coverage. **Generic product is available and is covered as an alternative to the brand-name product
Category CNS -- sedative/ hypnotics
CNS -- attention deficit hyperactivity disorder (ADHD)
CNS -- other
Dermatological
Not covered ATIVAN** (lorazepam)
Covered alternatives lorazepam
EDLUAR (sublingual zolpidem) INTERMEZZO* (sublingual zolpidem) ZOLPIMIST oral spray (zolpidem)
SILENOR (doxepin)
XANAX** (alprazolam)
XANAX**XR (alprazolam ER)
ADDERALL XR** (amphetamine dextroampetamine)
zolpidem tablets (generic AMBIEN)
doxepin (generic SINEQUAN) alprazolam alprazolam ER amphetamine dextroamphetamine cap er 24 hr
EVEKEO** (amphetamine sulfate)
amphetamine
ZENZEDI 2.5 mg, 7.5 mg, 15 mg, 20 mg, 30 mg (dextroamphetamine sulfate)
dextroamphetamine sulfate (generic DEXEDRINE)
GOCOVRI (amantadine extended release)
amantadine
NAMENDA XR** (memantine
memantine hcl cap er 24 hr
TRANSDERM SCOP** (scopolamine)
scopolamine transdermal patch
ZELAPAR (selegiline)
selegiline (generic ELDERPRYL)
ABSORICA (isotretinoin)
AMNESTEEM, CLARAVIS, MYORISAN
ACANYA gel pump (benzoyl peroxide /clindamycin)
BENZACLIN* (benzoyl peroxide/clindamycin) DUAC* (benzoyl peroxide/clindamycin) NEUAC* (benzoyl peroxide/clindamycin) ONEXTON (benzoyl peroxide/clindamycin)
Topical benzoyl peroxide plus clindamycin
APEXICON E CRE 0.05% (diflorasone diacetate) ATRALIN** (tretinoin) calcipotriene-betamethasone dipropionate oint
CAPEX (fluocinolone) CARAC* (fluorouracil) DENAVIR (penciclovir) ECOZA (econazole)
augmented betamethasone (cream/ointment/lotion/gel)
topical tretinoin (generic RETIN-A, ATRALIN)
calcipotriene CR, oint (generic DOVONEX); betamethasone CR, oint (generic VALISONE, DIPROSONE)
fluocinolone (generic SYNALAR)
topical fluorouracil (generic EFUDEX)
acyclovir capsules, tablets, ointment (generic ZOVIRAX)
econazole cream (generic SPECTAZOLE)
*Generic product is available and is also excluded from coverage. **Generic product is available and is covered as an alternative to the brand-name product
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